Carotid Bypass with Gore Hybrid Vascular Graft as a Rescue Technique for on Table Failed Carotid Endarterectomy: A Five Years Follow-up

Abstract

Introduction: Carotid endarterectomy (CEA) remains the gold standard for stenotic lesions involving the carotid bifurcation. Carotid bypass grafting is a suitable alternative technique especially in challenging and on table failed endarterectomy. We report our five years' experience using the Gore Hybrid vascular graft (GHVG) as a rescue technique when standard CEA failed. Methods: Between November 2014 and November 2018 nineteen GHVGs were used in patients undergoing CEA. All patients were scheduled for a routine endarterectomy and patch plasty. Pre-operative detailed duplex imaging was undertaken in all patients to measure the proximal and distal diameter of the internal carotid artery (ICA). The GHVG was used in eleven cases in which the plaque extended beyond the surgical exposure resulting in an unsatisfactory distal end point. Five patients had penetrating atherosclerotic ulcers causing a disruption of the posterior wall. Two cases had a significant wall thinning after the endarterectomy and in one case the bypass option was selected for a post-radiation induced stenosis. All patients were discharged on day 3 on dual antiplatelets and were followed up at 1 , 3, 6 ,12 months with duplex and CT angiogram . After one year the follow up continued regularly every six months using only duplex scan. CT angiogram was requested to monitor a severe restenosis. Kaplan Meir analysis was used for assessing the long term patency. Results: Procedural success was achieved in all cases. All patients made a good post-operative recovery with no perioperative stroke or death. The total operative time and cerebral ischaemic time was reduced because the avoidance of creating two sutured anastomosis. In six patients the external carotid artery (ECA) was re- implanted in an end to side fashion. Four GHVGs occluded during the follow-up at 6, 12,24 and 39 months completely asymptomatic. Five patients developed restenosis without any neurological events at 12, 13,15 20 and 28 months. Two patients underwent a carotid angioplasty and stenting for asymptomatic severe restenosis. The primary patency rate at 50 months was 78.9% Conclusion: The GHVG is a new promising technology in patients with extensive carotid atherosclerotic disease when conventional endarterectomy has failed. Our experience suggests a potential role of this graft in challenging case. Dual antiplatelets and long term follow up are needed to maintain the durability of this graft. Disclosure: Nothing to disclose